Insurance Claim Form - Outside Of Quebec - 2012
ADVERTISEMENT
1
2CLAIM FORM
CLAIM FORM
INSTRUCTION FOR THE INSURED
Before filling out this form, the claimant should carefully read the relevant sections of the policy. If the nature
of the disability is not consistent with contract conditions, he or she will thus avoid submitting a claim that
would be rejected.
The claimant must make every effort to answer each question separately, to provide complete answers and
to fill out all claim forms completely.
The claimant must cover all expenses related to producing evidence to support a claim.
TO BE FILLED OUT ENTIRELY BY THE INSURED
INSURED’S LAST NAME :
INSURED’S FIRST NAME :
SOCIAL INSURANCE NUMBER
TELPHONE NUMBER :
1
NUMBER AND STREET :
CITY :
PROVINCE :
POSTAL CODE :
2
POLICY NUMBER :
EFFECTIVE DATE OF INSURANCE :
DATE OF BIRTH :
3
YEAR
MONTH
DAY
4
5
6
PROFESSION OR OCCUPATION
Date at which you were unable to perform your
If you have resumed your profession or occupa-
profession or occupation :
tion, indicate your date of return :
___________________________________________________
Name of employer, where applicable :
YEAR : ____________ MONTH : ________
DAY : ________
YEAR : ____________ MONTH : ________
DAY : ________
7
8
PHYSICIAN’S NAME :
ADDRESS
Date at which you received medical care for the
first time in relation to this disability :
___________________________________________________
YEAR : ____________ MONTH : ________
DAY : ________
____________________________________________________
___________________________________________________
9
FOR HOSPITALIZATION (Send the Certificate of hospitalization)
NAME OF HOSPITAL
HOSPITALIZED FROM :
YEAR : ________ MONTH : ________ DAY : ________
TO
YEAR : ________ MONTH : ________ DAY : ________
10
TO BE FILLED OUT IN THE CASE OF ACCIDENT (For a fracture, send a copy of the radiologist’s report)
Did the accident occur at work
A)
B)
DATE OF ACCIDENT
?
YES
NO
Did the accident involve a motor
YEAR : ____________ MONTH : ________
DAY : ________
YES
NO
vehicle?
Other, specify :
Describe the circumstances of the accident (where and how)
C)
11
DID YOU SUBMIT A CLAIM
Worker’s Comp. WSIB, WCB?
Private or Government Automobile Insurance?
Under any other plan?
A)
B )
* C)
YES
NO
YES
NO
YES
NO
If so, name the plan :
*
To the best of my knowledge, the above declarations are true and complete and I hereby authorize any hospital
or physician who treated me to provide information to L’Excellence, Life Insurance Company.
DATE ____________________________
INSURED’S SIGNATURE ____________________________________________________________________
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
AUTHORIZATION
AUTHORIZATION
I hereby authorize any organization, hospital, physician or
I hereby authorize any organization, hospital, physician or
other person who has treated or examined me to communicate,
other person who has treated or examined me to communicate,
at any time, any information that such person or organization
at any time, any information that such person or organization
may hold concerning my health or my medical history to
may hold concerning my health or my medical history to
L’Excellence, Life Insurance Company or its representatives.
L’Excellence, Life Insurance Company or its reprensetatives.
______________________
____________________________________________
______________________
____________________________________________
Date
Insured’s signature
Date
Insured’s signature
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal